Back Pain Office Hours Telephone Triage Protocols | Adult | 2017

DEFINITION

⦁ Complains of upper, mid, or lower back pain that occurs mainly in the midline. ⦁ Not due to a traumatic injury ⦁ Minor muscle strain and overuse are covered in this guideline. Sciatic pain is also covered.

PAIN SEVERITY is defined as:

⦁ MILD (1-3): doesn't interfere with normal activities ⦁ MODERATE (4-7): interferes with normal activities or awakens from sleep ⦁ SEVERE (8-10): excruciating pain, unable to do any normal activities

Excluded:

⦁ Pain in the back from significant blunt or penetrating trauma should be triaged using the Back Injury guideline. ⦁ Pain in the lower back in pregnant women, consider labor. See Pregnancy - Labor and Pregnancy - Labor, Preterm guidelines.

TRIAGE ASSESSMENT QUESTIONS

Call EMS 911 Now Passed out (i.e., fainted, collapsed and was not responding) R/O: AAA FIRST AID: Lie down with feet elevated. Shock suspected (e.g., cold/pale/clammy skin, too weak to stand) R/O: AAA FIRST AID: Lie down with feet elevated. Sounds like a life-threatening emergency to the triager

See More Appropriate Protocol Major injury to the back (e.g., MVA, fall > 10 feet or 3 meters, penetrating injury, etc.) Go to Protocol: Back Injury (Adult) Pain in the upper back over the ribs (rib cage) that radiates (travels) into the chest Go to Protocol: Chest Pain (Adult) Pain in the upper back over the ribs (rib cage) and worsened by coughing (or clearly increases with breathing) Go to Protocol: Chest Pain (Adult) Go to ED Now SEVERE abdominal pain (e.g., excruciating)

Office Hours Telephone Triage Protocols | Adult | 2017 Page 1 Back Pain Abdominal pain and age > 60 R/O: compression fracture, aortic aneurysm Unable to urinate (or only a few drops) and bladder feels very full R/O: urinary retention, cauda equina syndrome Numbness (loss of sensation) in groin or rectal area

Go to ED/UCC Now (or to Office with PCP Approval) Sudden onset of severe back pain and age > 60 R/O: compression fracture, aortic aneurysm Pain radiates into groin, scrotum R/O: kidney stones Blood in urine (red, pink, or tea-colored)

Vomiting and pain over lower ribs of back (i.e., flank - kidney area)

Weakness of a leg or foot (e.g., unable to bear weight, dragging foot) R/O: nerve root impingement or cord compression Patient sounds very sick or weak to the triager Reason: severe acute illness or serious complication suspected Go to Office Now SEVERE back pain

Fever > 100.5° F (38.1° C) and flank pain R/O: pyelonephritis Pain or burning with urination R/O: pyelonephritis See Today in Office Can't walk or can barely walk R/O: severe back strain, cord compression Tingling or numbness in the legs or feet R/O: severe back strain, cord compression High-risk adult (e.g., history of cancer, history of HIV, or history of IV drug abuse) R/O: metastasis, epidural abscess Painful rash with multiple small blisters grouped together (i.e., dermatomal distribution or 'band' or 'stripe') R/O: herpes zoster (shingles) Pain radiates into the thigh or further down the leg, and in both legs Reason: bilateral sciatica carries higher risk

Office Hours Telephone Triage Protocols | Adult | 2017 Page 2 Back Pain See Today or Tomorrow in Office Pain radiates into the thigh or further down the leg R/O: sciatica Age > 50 and no history of prior similar back pain Reason: higher risk of serious medical cause Patient wants to be seen

See Within 2 Weeks in Office Back pain persists > 2 weeks

Back pain is a chronic symptom (recurrent or ongoing AND lasting > 4 weeks)

Home Care Back pain R/O: muscle strain, overuse Caused by a twisting, bending, or lifting injury R/O: muscle strain, overuse Caused by overuse from recent vigorous activity (e.g., exercise, gardening, lifting and carrying, sports) R/O: muscle strain, overuse Preventing back strain, questions about

HOME CARE ADVICE

Back Pain

1. Reassurance: ⦁ Twisting or heavy lifting can cause back pain. It can also occur after un-noticed minor back injuries ⦁ With treatment, the pain most often goes away in 1-2 weeks. ⦁ You can treat most back pain at home. ⦁ Here is some care advice that should help. 2. Cold or Heat: ⦁ Cold Pack: For pain or swelling, use a cold pack or ice wrapped in a wet cloth. Put it on the sore area for 20 minutes. Repeat 4 times on the first day, then as needed. ⦁ Heat Pack: If pain lasts over 2 days, apply heat to the sore area. Use a heat pack, heating pad, or warm wet washcloth. Do this for 10 minutes, then as needed. For widespread stiffness, take a hot bath or hot shower instead. Move the sore area under the warm water. 3. Sleep: ⦁ Sleep on your side with a pillow between your knees. If you sleep on your back, put a pillow under your knees. ⦁ Avoid sleeping on your stomach. ⦁ Your mattress should be firm. Avoid waterbeds.

Office Hours Telephone Triage Protocols | Adult | 2017 Page 3 Back Pain 4. Activity: ⦁ Keep doing your day-to-day activities if it is not too painful. Staying active is better than resting. ⦁ Avoid anything that makes your pain worse. Avoid heavy lifting, twisting, and too much exercise until your back heals. ⦁ You do not need to stay in bed. 5. Pain Medicines: ⦁ For pain relief, you can take either acetaminophen, ibuprofen, or naproxen. ⦁ They are over-the-counter (OTC) pain drugs. You can buy them at the drugstore. Acetaminophen (e.g., Tylenol): ⦁ Regular Strength Tylenol: Take 650 mg (two 325 mg pills) by mouth every 4-6 hours as needed. Each Regular Strength Tylenol pill has 325 mg of acetaminophen. ⦁ Extra Strength Tylenol: Take 1,000 mg (two 500 mg pills) every 8 hours as needed. Each Extra Strength Tylenol pill has 500 mg of acetaminophen. ⦁ The most you should take each day is 3,000 mg (10 Regular Strength or 6 Extra Strength pills a day). Ibuprofen (e.g., Motrin, Advil): ⦁ Take 400 mg (two 200 mg pills) by mouth every 6 hours. ⦁ Another choice is to take 600 mg (three 200 mg pills) by mouth every 8 hours. ⦁ The most you should take each day is 1,200 mg (six 200 mg pills), unless your doctor has told you to take more. Naproxen (e.g., Aleve): ⦁ Take 220 mg (one 220 mg pill) by mouth every 8 hours as needed. You may take 440 mg (two 220 mg pills) for your first dose. ⦁ The most you should take each day is 660 mg (three 220 mg pills a day), unless your doctor has told you to take more. 6. Pain Medicines - Extra Notes: ⦁ Use the lowest amount of medicine that makes your pain better. ⦁ Acetaminophen is thought to be safer than ibuprofen or naproxen in people over 65 years old. Acetaminophen is in many OTC and prescription medicines. It might be in more than one medicine that you are taking. You need to be careful and not take an overdose. An acetaminophen overdose can hurt the liver. ⦁ McNeil, the company that makes Tylenol, has different dosage instructions for Tylenol in Canada and the United States. In Canada, the maximum recommended dose per day is 4,000 mg or twelve Regular-Strength (325 mg) pills. In the United States, McNeil recommends a maximum dose of ten Regular-Strength (325 mg) pills. ⦁ Caution: Do not take acetaminophen if you have liver disease. ⦁ Caution: Do not take ibuprofen or naproxen if you have stomach problems, kidney disease, are pregnant, or have been told by your doctor to avoid this type of anti-inflammatory drug. Do not take ibuprofen or naproxen for more than 7 days without consulting your doctor. ⦁ Before taking any medicine, read all the instructions on the package. 7. Call Back If: ⦁ Numbness or weakness occur ⦁ Bowel/bladder problems occur ⦁ Pain lasts for more than 2 weeks ⦁ You become worse Preventing Back Strain

1. Prevention: ⦁ The only way to prevent future backaches is to keep your back muscles in excellent physical

Office Hours Telephone Triage Protocols | Adult | 2017 Page 4 Back Pain condition. ⦁ A sedentary lifestyle (lack of exercise) is a risk factor for developing back pain. ⦁ Walking, stationary biking, and swimming provide good aerobic conditioning as well as exercise for your back. ⦁ Being overweight puts more weight on the spine and thus increases the risk of back pain. If you are overweight, work with your doctor to develop a weight-loss program. 2. Good Body Mechanics: ⦁ Lifting: Stand close to the object to be lifted. Keep your back straight and lift by bending your legs. Ask for lifting help if needed. ⦁ Sleeping: Sleep on a firm mattress. ⦁ Sitting: Avoid sitting for long periods of time without a break. Avoid slouching. Place a pillow or towel behind your lower back for support. ⦁ Posture: Maintain good posture. 3. Strengthening Exercises: ⦁ During the first couple days after an injury, strengthening exercises should be avoided. The following exercises can help strengthen the back. Perform the following exercises 3-10 times each day, for 5-10 seconds each time. ⦁ Bent knee sit-ups: Lay on back, curl forward lifting shoulders about 6 inches (15 cm) off the floor. ⦁ Leg lifts: Lay on back, lift foot 6 inches (15 cm) off floor (one leg at a time). ⦁ Pelvic tilt: Lay on back with knees bent, push lower back against floor. ⦁ Chest lift: Lie face down on ground, place arms by your sides, lift shoulders off the floor. 4. Call Back If: ⦁ You have more questions ⦁ You become worse

FIRST AID

FIRST AID Advice for Shock: Lie down with the feet elevated.

BACKGROUND INFORMATION

Key Points

⦁ Lower back pain is a cause of countless visits to physicians' offices and emergency departments. It is the second most common cause of lost workdays, after cold and flu symptoms. Over 80% of people at some point in their lives have lower back pain. ⦁ However, there is some good news. In most cases, the back pain is not serious and it has a self- limited course. Pain subsides within 4-6 weeks in 90% of individuals experiencing acute low back pain.

Four Categories of Back Pain

⦁ Potentially serious: Examples include abdominal aortic aneurysm, neoplasm, osteomyelitis, epidural abscess, vertebral fracture, and neurologic emergencies (e.g., cauda equina syndrome). ⦁ Sciatica (back pain with neurologic symptoms): There is radiation of the back pain (or buttock pain) into a lower extremity suggesting lumbosacral nerve root compression. There may be associated leg weakness, numbness, or paresthesias.

Office Hours Telephone Triage Protocols | Adult | 2017 Page 5 Back Pain ⦁ Non-specific back pain: No neurologic symptoms. Examples include lumbar strain/sprain, degenerative osteoarthritis, lumbar disc disease, and fibromyalgia. ⦁ Referred back pain: There are gastrointestinal causes like pancreatitis, biliary colic, and posterior gastric ulcer; genitourinary causes like renal colic, pyelonephritis, endometriosis, and ovarian cyst.

Lumbar Strain

⦁ Acute lower back pain in the 18 to 50 year old age group is usually a symptom of strain of some of the 200 muscles in the back that allow us to stand upright. ⦁ Often the triggering event is carrying something too heavy, lifting from an awkward position, bending too far backward or sideways, or overuse. ⦁ Individuals with strained back muscles often note that the pain is increased by bending or twisting movements, relieved by assuming certain positions, and that the back muscles are tender.

Degenerative Osteoarthritis

⦁ Degenerative osteoarthritis is a common cause of back pain in the elderly population. ⦁ In uncomplicated osteoarthritis, individuals will complain of chronic midline back discomfort. Frequently, there is morning stiffness that improves as the day progresses.

Bed Rest and Overtreatment

⦁ Complete bed rest is inconvenient and unnecessary in the majority of patients, including those who need to be examined by the physician. Complete bed rest should never be recommended over the telephone. ⦁ Research has demonstrated that continuing ordinary activities within the limits permitted by pain results in a speedier recovery than rest [Malmivaara reference].

REFERENCES 1. Argoff CA. Spinal and radicular pain disorders. Neurol Clin. 1998;16(4):833-50.

2. Atlas SJ, Nardin RA. Evaluation and treatment of low back pain: an evidenced-based approach to clinical care. Muscle & Nerve. 2003;27(3):265-84. 3. Chou R, Huffman LH; American Pain Society; American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians. Clin. Practice Guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504. 4. Dart RC, Kuffner EK, Rumack BH. Treatment of pain or fever with paracetamol (acetaminophen) in the alcoholic patient: a systematic review. Am J Ther. 2000 Mar;7(2):123-34. 5. Devereaux MW. Low back pain. Prim Care. 2004; 31(1): 33-51.

6. Deyo RA, Weinstein JN. Low back pain. N Eng J Med. 2001;344:363-9.

7. Divoll M, Abernethy DR, Ameer B, Greenblatt DJ. Acetaminophen kinetics in the elderly. Clin Pharmacol Ther. 1982 Feb;31(2):151-6. 8. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004750.

Office Hours Telephone Triage Protocols | Adult | 2017 Page 6 Back Pain 9. Griffin G, Tudiver F, Grant WD. Do NSAIDs help in acute or chronic low back pain? Am Fam Physician. 2002;65(7):1319-21. 10. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD001254. 11. Hilde G, Hagen KB, Jamtvedt G, Winnem M. Advice to stay active as a single treatment for low back pain and sciatica. Cochrane Database Syst Rev. 2002;(2):CD003632. 12. Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD003974. 13. Kovacs FM, Abraira V, Pena A: Effect of firmness of mattress on chronic non-specific low- back pain: randomised, double-blind, controlled, multicentre trial. Lancet. 2003 Nov 15;362(9396):1599-604. 14. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain: bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351-355. 15. Rainsford KD. Ibuprofen: pharmacology, efficacy and safety. Inflammopharmacology. 2009 Dec;17(6):275-342. 16. Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Non-steroidal anti- inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000396. 17. Swenson R Lower back pain; differential diagnosis: a reasonable clinical approach. Neurol Clin. 1999;17(1):43-63. 18. Takala E. Immediate referral from general practice for lumbar spine X-ray does not improve quality of life or pain for people with lower back pain. Evidence-based Healthcare. 2002; 6(2);91-92.

AUTHOR AND COPYRIGHT

Author: David A. Thompson, MD, FACEP Copyright: 2000-2017, LaGrange Medical Software, Inc.. All rights reserved. Company: Schmitt-Thompson Clinical Content Content Set: Office Hours Telephone Triage Protocols | Adult Version Year: 2017 Last Revised: 5/15/2016 Last Reviewed: 4/10/2017

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